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Med Surg HESI II1. Community Hlth/Medical Surgical- Respiratory – COPD- SS!

cough (chronic intermittent; usually occurs in morning w/ or w/o sputum)" sputum production"

dyspnea (progressive; occurs with exertion then becomes present at rest)" &/or history of exposuto risk factors "Wheezing chest tightness

#. Critical Care/$undamentals/Medical Surgical – Med %dministration/Math – &' insulin rate! starat (.1 units/)g/hr *y continuous in+usion

,. Critical Care/Medical Surgical – Immune/Hematology – PRBC- infusion:

• !onsent form signed

•  "yping & crossmatching

• #$ before admin

• %lood should be administered w/in ' minutes of arrival from blood bank

• emain with pt for rst *+ min of infusion; rate should not exceed ,m-/min; #$ every + fo

rst *+ min

• .f no untoward reaction rate can be increased

•

bserve pt every ' min•  "ransfusion should not exceed 0 hours1 .f pt is not in danger of 2uid overload they can rec

* unit in , hours1

undamentals- Basic nursing s!ills/"ygiene- Posto# drainage

-Know the type of wound, the drains inserted and know expected drainage

- Drainage is expected to change from sanguineous (red to serosanguineous (pink to serous (ye!!ow" It shouecrease o#er hours or days, depending on the type surgery"

- $uru!ent drainage means infection

undamentals- Basic nursing s!ills/nutrition- %so#"ageal &arices- diet

- Do not ingest a!coho!, aspirin, %S&ID's and irritating foods

undamentals- med administration/mat"- I(- He#arin ml/"r*eriatrics/ medSurg- *I/He#atic/+ncology-Colon cancer-intestinal #oly#s

o!onoscopy, sigmoidoscopy, )arium enema, and *+MI co!onoscopy are use to disco#er po!yps" E#en though the

most common types po!yps are nonneop!astics, a!! po!yps are consider a)norma! and shou!d )e remo#e co!onoscopy

roffered since it e#a!uates the who!e co!on and remo#e po!yps at same time, sigmoid wi!! on!y remo#e the !ast part"re non specific ( diarrhea and a!ternating with constipation and sometimes anemia, and usua!!y appear !ate in the

isease" *he !i#er is common site of metastasis ( through the porta! #ein and then the cancer spreads from the !i#er t

ther sites" $eop!e with a#erage risk shou!d ha#e a co!onoscopy once a year starting form age ./, &frican &mericanshou!d start at 0., if high risk shou!d start ear!ier" --- the book doesn't specify anything about geriatrics but I assume

hat since older pt usually have GI/ anemia issues it might be easy to ignore some of the s/s. also the older the higher

sk for any type of cancer.

MedSurg-Cardio&ascular-ngina-Pro#"ylacticItrog!ycerine ta)!ets, sprays, or ointments may )e used prophy!actica!!y )efore emotiona!!y stressfu! situation, sexu

ntercourse, or physica! exertion (e"g", c!im)ing a !ong f!ight of stairs" $g" 121"

MedSurg-Cardio&ascular-MI-"rom0olytics

hrom)o!ytics to stop an MI shou!d )e gi#en as soon as possi)!e and )efore 3 hours from when the symptoms started

i)rino!ytics are gi#en I5" ommon hospita! protoco!s are -67 !ead E8, draw )!ood to o)tain )ase!ine !a)s, initiate

nes for I5 therapy" Depending on the drug se!ected" *o asses effecti#eness of drug therapy the most re!ia)!e markerhe return of the S* segmented to )ase!ine on the E8, other markers inc!ude reso!ution of chest pain, and ear!y rapi

se of the K-M: en;ymes within 9 hours and peaking at 67 hours" *o pre#ent other c!ots from forming, I5 heparin

herapy is initiated" &)so!ute contraindications< acti#e )!eeding, history of aneurism or arterio#enous ma!formation,ntracrania! neop!asm, pre#ious cere)ra! hemorrhage, recent (within 9 months ischemic stroke, head or facia! trauma

ithin 9 months, suspected aortic dissection" aution< recent (within 9 weeks of surgery, recent (7-9 weeks interna!

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!eeding --yes this is what the book says

(. Medical Surgical-Cardioascular- Pacema)er- assessnot *''4 sure what this 5uestion was looking for (pg 67)everal measures can assess for complications and include prophylactic .# antibiotic therapyefore and after insertion post insertion chest x8ray to check lead placement and to rule out resence of pneumothorax careful observation of insertion site and continuous 9!:

monitoring of the patients rhythm1 bserve insertion site for signs of bleeding and check thahe insertion is intact1 fter discharge patients will neeo check pacemaker function on a regular basis which can involve outpatient visits to aacemaker interrogator/programmer or home monitoring using telephone transmitter devicenother method to evaluate pacemaker performance is noninvasive program stimulation wh

s done outpatient in the electrophysiology laboratory1

1. Medical Surgical-Cardioascular- Right sided heart +ailureauses a backup of blood into the right atrium and venous circulation1 #enous congestion in tystemic circulation results in ?ugular venous distention hepatomegaly splenomegaly vascuongestion of the :. tract and peripheral edema1 "he primary cause of 8sided heart failure eft8sided heart failure1 .n this situation left8sided failure results in pulmonary congestion and

ncreased pressure in the blood vessels of the lung (pulmonary hypertension)1 9ventuallyhronic pulmonary hyptertension (increased ventricular afterload) results in right8sidedypertrophy and failure1 !or @ulmonale ( ventricular dilation and hypertrophy caused byulmonary disease) can also cause right8sided heart failure1 (pg 6'')

#. Medical Surgical-Cardioascular- SM&- assess throm*olysisssociated with the deterioration of a once stable atherosclerotic pla5ue that ruptures exposhe intima to blood and stimulating platelet aggregation and local vasoconstriction withhrombus formation1 "his unstable lesion is totally occluded by a thrombus(manifesting as a"9=.)1 =. occurs because of sustained ischemia causing irreversible cell death1 When ahrombus develops perfusion to the myocardium is halted distal to the occlusion resulting in

ecrosis1 "reatment of =. with brinolytic therapy aims to stop the infarction process byissolving the thrombus in the coronary artery and reperfusing the myocardium1herapy is given as soon as possible and within the rst A hours of onset of symptoms1 9achospital has a protocol for administering "@> (*)chest pain typical of =. (,) *, lead 9!: ndinonsistent with acute =. and () no absolute contraindications (table 08*0)1 (pg 76,8)

,. Med Surge – Cardioascular – lectrical 0urns pg. 2324• Bysrhythmias cardiac arrest #8b can result at in?ury or anytime within ,0 hours after in?ury1

• =onitor airway vital signs cardiac rhythm .&

2. Med Surge – ndocrine – Dia*etes %1c leel pg. 1##1" 1##,4

• >t risk for diabetesC +178A104• =aintaining an >*c D74 decreases diabetes complications microvascular and neuropathic

• =aintaining an >*c DA4 may further reduce complications but increases hypoglycemia risk

5. Med Surge – ndocrine – 6raes7 Disease E autoimmune disease marked by diFusehyroid enlargement and excessive thyroid hormone secretion1 Bevelop antibodies to "$Geceptor causing release of " and "0 excessive amounts of "G develops clinical manifestatif thyrotoxicosis1 Bisease is characterized by remissions and exacerbations1 Hntreated leads ypothyroidism E treat with $ynthroid1 (pg1 *,A0)

8. ndocrine/Physical %ssessment – Hyperthyroid symptoms!

is a hyperacti#ity of the thyroid g!and with sustained increase in synthesis and re!ease of thyroid hormones" *his

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sua!!y occurs in women more than men, with the highest fre=uency in persons 7/-0/ years of age" *he most commorm is 8ra#es Disease" >ther causes inc!ude toxic nodu!ar goiter, thyroiditis, excess iodine intake, pituitary tumors,

hyroid cancer"

ymptoms< Increased circu!ating thyroid hormone direct!y increases meta)o!ism causing an increase in appetite witheight !oss, tissue sensiti#ity to stimu!ation )y the S%S (i"e" ner#ousness, pa!pations" & goiter may )e present upon

ssessment" &uscu!tation of the thyroid g!and may re#ea! )ruits" Exophtha!mos (protrusion of the eye)a!!s, rapid spe

nd into!erance to heat" $g 6730

). %ndocrine/Res#iratory-trac"eostomy-#arat"yroidectomy< *racheostomy is a surgica! incision into the tracheor the purpose of esta)!ishing an airway" & tracheostomy is the stoma (opening the resu!ts from the tracheotomy"

ndications for a tracheostomy< 6" :ypass the upper airway o)struction, 7" 4aci!itate the remo#a! of secretions, 9" $er

ong-term mechanica! #enti!ation, 0" $ermit ora! intake and speech in the pt who re=uires !ong-term #enti!ation" $g .arathyroidectomy- *he most effecti#e treatment of primary and secondary hyperparathyroidism is a parathyroidecto

ecause it !eads to a rapid reduction of high ca!cium !e#e!s" ritera for surgery inc!ude ca!cium !e#e!s greater than 67

mg+d?, hyperca!ciuria (@0// mg+day, marked!y reduced )one minera! density, and those under ./ years of age" %urare for a pt with a parathyroidectomy is simi!ar to that for a pt with a thyroidectomy" *he maAor post-op comp!icati

re from hemorrhage and f!uid and e!ectro!yte distur)ances" *etany (hyperexcita)i!ity associated with a decrease in

a!cium !e#e!s is another concern"

,. *I/He#atic –Bariatric surgery-#ost o# care and diet: the initia! post-op care focuses on carefu! assessment anmmediate inter#ention for cardio pu!monary comp!ications, throm)us formation, anastomosis !eaks, and e!ectro!yte

m)a!ances" During the transfer from surgery, the pt's airway shou!d remain sta)i!i;ed and maintain pain !e#e!s" Main

he head of the pt at 9.-0/ degrees to reduce a)domina! pressure and increase tida! f!ow" If the pt is o)ese, monitor fapid >7 desaturation" Ear!y am)u!ation is essentia! (the same e#ening after the surgery" *ed Hose wi!! )e p!aced rig

way and passi#e >M exercises wi!! )e fre=uent" ?ow dose heparin might )e ordered" 4re=uent assessment of the s

o monitor for de!ayed wound hea!ing, hematomas, wound dehiscence" Keep skin fo!ds c!ean and dry to pre#entermatitis and funga! infections" $ain management is critica!" $g B.2

uring immediate post-op, water and sugar-free !i=uids are gi#en (9/m! e#ery 7 hours" :efore discharge instruct pt

measured amount of a high protein diet" *each the pt to eat s!ow!y and stop when fee!ing fu!! and not to consume

=uids with so!id foods" *he pt is forced to reduce the ora! intake and the ot finds the adherence to a reduced intake ecessary )ecause of the concern for a)domina! distention and diarrhea" *he diet shou!d )e high in protein and !ow i

ar)s, fat, and roughage and consists of 3 sma!! feedings a day" 4!uid restriction of C 6,/// m!+day" 4!uids and foods

re high in car)s promote diarrhea and dumping syndrome"

. 2i&erticulitis- 3P+

n acute di#erticu!itis, the goa! of treatment is to !et the co!on rest and the inf!ammation to su)side" &t home some

atients are put on anti)iotics and a c!ear !i=uid diet" If t"e #atient is "os#italied and una0le to tolerate oral fluid

"e #atient 6ill 0e !e#t on 3P+ status and 0ed rest5 I( fluids and anti0iotics 6ill 0e gi&en. >)ser#e for signs o

)scess, )!eeding, and peritonitis" &nd monitor the : count" hen the acute attack su)sides s!ow!y introduce or

uids and then progress the diet to semiso!ids"

8. *%R2- #g )7

8astrointestina! ref!ux disease defined as chronic symptoms or mucosa! damage secondary to ref!ux of gastri

ontents into the !ower esophagus" Heart )urn is the most common c!inica! manifestation, a )urning, tighteningensation fe!t intermittent!y )eneath the !ower sternum and spreading upward into the throat and Aaw" Some patients

so comp!ain of pain in the upper a)domen (Dyspepsia" %oncardiac chest pain is common in o!der adu!ts with 8E

?ifesty!e modifications- a#oid foods that trigger symptoms" weight reduction may he!pif the patient is#erweight" Encourage patient to stop smoking

 %utritiona! therapy- a#oid foods that cause ref!ux" oid eating at night )efore )ed"

Drug therapy-$$Is $ri!osec, %exium, $rotonix, $re#acid, dexi!ant, aciphex

H7 receptor )!ockers- *agamet, antac, $epcid, &xid,

&ntiu!cer drug- arafate

1. Hiatal Hernia- #g )$

erniation of a portion of the stomach into the esophagus through the opening, or hiatus, in the diaphragm" Most

atients are usua!!y asymptomatic" hen symptoms to occur they are simi!ar to 8ED" :ending o#er with se#ere p

ain with !arge mea!s, a!coho! and smoking"

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onser#ati#e therapy- !ifesty!e modifications, decrease of intra-a)domina! pressure, a#oid !ifting and straining, donmoke or drink a!coho!, e!e#ate the head of the )ed, reduce )ody weight, use antisecretory agents ($$Is, and H7 rece

!ockers and antacids

urgica! therapy- herniotomy, herniorraphy, gastropexy

7. *I/"e#atic/immune/"ematology9Cirr"osis9"ematemesis< !ater symptoms of cirrhosis may )e se#ere and re

om !i#er fai!ure and porta! hypertension" $orta! hypertension may cause )!eeding esophagea! or gastric #arices, cau

he pt to ha#e me!ena or hematemesis" *he main tx goa! is to pre#ent )!eeding of the #arices" *x of )!eeding #aricesnc!udes #asopressors, nitrog!ycerin, )eta-)!ockers, )and !igation, endoscopic sc!erotherapy, F )a!!oon tamponade"

upporti#e measures during a #arice )!eed inc!ude< 44$+packed :s, #itamin K, H7 )!ockers and $$Is, !actu!ose, a

rophy!actic a)x" May need a %8* to !a#age stomach+get )!ood out"

. *I/He#atic/o#erati&e9Posto# diet< a#oidance of hepatotoxins, such as a!coho! and *y!eno!, is critica!" $t shou

#oid spicy and rough foods and acti#ities that increase porta! hypertension (straining during :Ms, coughing, snee;in

etching, #omiting" &de=uate ca!ories shou!d )e ingested (suggest sma!!, fre=uent high-protein, high-ca!orie mea!s"May )e prescri)ed #itamin K and : comp!ex #itamins"

4. Immune/"ematology/integumentary/sensory9S"ingles #ain< herpes ;oster+shing!es< grouped erythematous sk

nd #esic!es and pustu!es appear in a !inear distri)ution a!ong a dermatome" *x inc!udes anti#ira! agents (&cyc!o#ir

ompresses, F Si!#adene to ruptured #esic!es" 4or ana!gesia, may use mi!d sedation at )edtime F ga)apentin"

$. Musculos!eletal/r"eumatoid art"ritis- ES change< aised erythrocyte sedimentation rate (ES signa!s heart

ai!ure in patients with rheumatoid arthritis" $atients with & ha#e an increased risk for heart and circu!atory conditio

nc!uding coronary artery disease, heart attack, atria! fi)ri!!ation and stroke" *hey may a!so face higher risks for #enohrom)oem)o!ism (5*E and pu!monary em)o!ism

'. P"ysical assessment of trousseau sign< !atent tetany, the occurrence of carpopeda! spasm accompanied )yaresthesia e!icited when the upper arm is compressed, as in use of a tourni=uet or a )!ood pressure cuff" *his is an

)Aecti#e assessment sign of hypoca!cemia

). t"lete;a foot anti fungal< c!otrima;o!e (!otramin is an antifunga! used to treat yeast infections of the #agina,mouth, and skin (ath!etes foot" Gse with caution if you ha#e hepatic impairment, monitor ?4*s, prey category c

,. Musculos!eletal-*out medication - &cute gouty arthritis is treated with co!chicine and %S&IDs" :ecauseo!chicines ha#e anti-inf!ammatory effects )ut no ana!gesic properties, %S&ID is added to the treatment regimen for

ain management" 8i#en $>, pain re!ief is expected within 70-02 hours" ecurrent gout can )e pre#ented )y com)in

o!chicines with a xanthine oxidase inhi)itor !ike a!!opurino! or a uricosuric drug !ike :enemid , G!oric, a se!ecti#enhi)itor of xanthine oxidase, is gi#en for !ong-term mngt of hyperuricemia" If they don't respond to drugs to !ower u

cid, they may )e gi#en Krystexxa that meta)o!i;es uric acid and is excreted in urine, gi#en I5" &*H may a!so trea

out"

de=uate urine #o!ume w+ norma! rena! function (7-9?+day must )e maintained to pre#ent uric acid in the rena! tu)ui#e &!!opurino! in patients with uric acid stones" Ha#e pt !imit a!coho! use and consumption of foods high in purine

. Musculos!eletal- S!eletal traction-mo0ility - Ske!eta! traction, genera!!y in p!ace for !onger periods then skin

actions and is used to a!ign inured )ones and Aoints or to treat Aoint contractures and congenita! hip dysp!asia" & pin

ire is p!aced into the )one to a!ign and immo)i!i;e the inAured )ody part" t" for ske!eta! traction ranges from .-0. nd must )e hanging free!y" $re#ent externa! hip disp!acement )y p!acing a pi!!ow, sand)ag, or ro!!ed up draw sheet

ong the greater trochanteric region" $t" shou!d )e in the center of the )ed in a supine position" Incorrect a!ignment c

esu!t in increased pain and nonunion or ma!union" *o offset the pro)!em of immo)i!ity, discuss specific patient acti#

ith the hea!thcare pro#ider" If exercise is permitted, encourage patient to participate in acti#ities such as fre=uentosition changes, >M exercise of unaffected Aoints, deep-)reathing exercises, isometric exercises, and use o the tra

ar as permitted

8. 3eurological-

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1. 9eurological- meningitis-step one pg *0+,meningitis8 acute in2ammation of the meningeal tissues surrounding the brain and spinal cord1

st step8 guring out if the pt has meningitis and starting them on meds/antibiotics; Biagnosisistory/psychical check to see if the pt is presenting $/$ (meningitis triad; fever stiF neck altered

mental status) pt will get blood culture !$I sample (lumbar puncture) sputum and nasopharyngeaecretions collected before starting antibiotics therapy but after collection before the results are backhey will start the patient on a cocktail of antibiotics1

#. 9eurological- Sei:ure- home care pg *+''ei:ure-paroxysmal uncontrolled electrical discharge of the neurons in the brain that interrupts norm

unction1ome care- table +J8*,

• drug compliance

• non8 drug therapy (e1g1 relaxation methods)

• be aware of resource in community

• risk factors; avoid alcohol fatigue loss of sleep

• good nutrition habits snacks when needed

• recogni;e persona! !imitations

• education for care gi#ers (pt safety, first aid

,. Oncology-&n+ection- chemo ris) pg ,6'

eutropenia is most common in pt receiving chemo places pt at serious risk for infection and sepsis1and hygiene is ma?or with chemo pt1t blood count will be lowest between 78*' after therapymaking the pt even more susceptible to

nfection1 =onitoring pt vitals and any sign of infection is crucial1 >ny sign of fever *''1+ or greater ismedical emergency1

4. Medical surgical – +ncology / Renal – llo#urinol – Prior to c"emot"era#y

&!!opurino! is a medication for the treatment of gout that !owers the amount of uric acid in the )!ood

Since chemotherapy ki!!s cancer ce!!s, ce!!s )reak open and spi!! their contents into the )!ood stream" *his can causeerious pro)!ems such as kidney damage ca!!ed *umor !ysis syndrome

Gric acid is formed from the )reakdown of these ce!!s, so &!!opurino! )!ocks this process to !ower the amount of Gr

cid in the )!ood

$. Medical surgical – Renal – R-luid c"allenge =cute Renal ailure>

Essentia!!y, a !arge amount of f!uid (6-7 !iters, or 7./m? of co!!oid (*he point is that the kidneys are presented with

ha!!enge that can )e monitored are infused into a #ein whi!e kidney function is monitored for signs of f!uid o#er!oa#er!oad is o)ser#ed, further testing can )e conducted"

'. Medical surgical – Renal – Hy#er!alemia-dialysis

Hyperka!emia is common in patients with end-stage rena! disease

5 ca!cium can )e used to sta)i!i;e the myocardium

$E5E%*I>% ES*S ?&8E?J >% DIE*&J >M$?I&%E MED E8IME%

Mi!d e!e#ations< Kayexa!ate and 4urosemideDI&?JSIS IS GSED 4> >G*I%E EME8E%* %EEDS >4 SE5EE E?E5&*I>%S

$oint is that dia!ysis is the u!timate treatment for this, )ut there are many other ways"

). Medical Surgical – Renal – Ileal conduit- #ost-o# com#lications

!ea! conduit L 4orm of incontinent urinary di#ersion" In this procedure a 3 to 2 inch segment of the i!eum is con#ert

nto a conduit for urinary drainage" *he ureters are anastomosed into one end of the conduit, and the other end of theowe! is )rought out through the a)domen to form a stoma"

isk for impaired skin integrity L ensure ostomy app!iance fits appropriate!y to protect skin from urine exposure, mo

oma and surrounding tissue, change )ag appropriate!y to pre#ent urine !eakage onto skin, do %>* use a!ka!ine soapurrounding skin

enera! postop comp!ications L postop ate!ectasis and shock, throm)oph!e)itis, sma!! )owe! o)struction, G*I, para!y

eus ( wi!! )e kept %$> and on %8 tu)e for se#era! days postop since part of the )owe! was remo#ed,

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,. Medical Surgical – Renal – Renal lit"otri#sy- #osto# care

ithotripsy L procedure used to e!iminate ca!cu!i from the urinary tract" $ostop re=uires ana!gesics, hematuria is

ommon, stent often p!aced to faci!itate shattered ca!cu!i"

ostop care L dietary modifications (increase water intake, !imit co!as, coffee, and tea, !imit sodium and oxa!ate richoods, monitor urinary e!imination (fre=uency, co!or, odor, #o!ume, consistency, monitor for G*I, assess and treat p

. Medical Surgical – Renal/ Re#roducti&e – BPH – nocturia difficulties

rinate = 7-9 hours and when first fee!ing the urge, use a toi!eting schedu!e" ontinue to drink ade=uate f!uids, )ut a#

xcess f!uid intake )efore )ed" &ssess how many times patient gets up to #oid, whether or not the urge awakens theatient, and how it interferes with their s!eep" >ther a!ternati#es inc!ude indwe!!ing catheter, drug therapy (.a reduct

nhi)itors, a-adrenergic receptor )!ockers, minima! in#asi#e therapy, or in#asi#e therapy"

(. Reproductie esticular Cancer!are !ancer occurs between ages *+80 , typesC $eminoma germ cell (not aggressive)onseminoma (very aggressive)xC painless and rm lump on scrotum scrotal swelling feeling of heaviness or acheiness acain only occurs in *'4 of patientsx of metastasisC back pain cough dyspnea hempotysis dyshpagia alterations in vision or

mental status papilledema and seizuesxC @alpation is rst test then an ulatrasound is doneursing !areCeach pt1 testicular self examinationC encourage man to preform self examinations once a on

while in shower (easiest time) use both hands to feel each testis and roll testis between thehumb and rst three ngers until entire surface as been covered1 palpate separately1 .dentiftructures (testes and epididymis) testes should be round and smooth and epididymis is nos smooth as testes1 one may be bigger than the other1 -ook for lumps irregularities pain oragging sensationare for !ancerC orchiectomy (removals of aFected testes spermatic cord and regional lympodes) !an be done in con?unction with chemo with patients in late stage cancer1xC J+4 chance of complete remission if detected in early stages1

nfertilityC @rior infertility or impaired fertility is often present at dx time1 !hemo can causenfertility1 "alk about cryopreservations of sperm in sperm bank?aculatory dysfunction may occur with removal of the lymph node1

=en may feel less manly and lose self worth1 @g *JA8*J7

1. Res#iratory: de?uate gas e@c"ange<he a)i!ity of the !ungs to oxygenate arteria! )!ood ade=uate!y is determined )y the examination of the $a>7 (3/-2/m

g and Sa>7 (a)o#e B/" *ested through &:8Ns

x of Inade=uate gas exchange< hange in ?>, tachypnea, dyspnea, use of accessory musc!es, retraction of interspan inspiration, pause for )reath )etween sentences and words, tachycardia, mi!d hypertension, dysrhythmia, hypoten

yanosis, coo!, c!ammy skin, decreased urinary output, fatigue

7. Res#iratory: ids in *as e@c"ange

reat under!ying cause (pre#ent aspiration, gi#e anti)iotics to c!ear any f!uid or mucus in the !ungs, remo#e o)structi

ith histamines+epi or *$& to c!ear c!ot, , >7 support, deep )reathing, incenti#e spriometer, donNt smoke, pursed !ipreathing, huff coughing, acape!!as

. Res#iratory – Burns – Smo!e In"alation

• Irom hot air or noxious chemicals E redness and airway swelling may result in?uries are ma?or

predictor of mortality so rapid assessment is critical

• !arbon =onoxide @oisoning E causes carboxyhemoglobinemia (oxygen displaced from hemoglo

by carbon monoxide) E skin color Kcherry redL and sometimes no burns on skin

• .nhalation in?ury above the glottis (upper airway in?ury) E usually thermally produced by hot air

steam or smoke E mucosal burns that are red blistering and edema present1 =echanical

obstruction can occur 5uickly M medical emergency1

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o !luesC facial burns singed nasal hair hoarseness painful swallowing darkened oral and

nasal membranes clothing burns around chest and neck1

• .nhalation in?ury below the glottis (lower airway in?ury) E usually chemically produced tissue

damage related to duration of exposure1 !linical manifestations like pulmonary edema may no

appear until *,8,0hrs after burn and may manifest as >B$

• @ts need to be observed closely for resp1 distress and transfer to burn center if carbon monoxid

poisoning suspected treate with *''4 humidied oxygen

• :ood "able on pg 076C assessment ndings E rapid slow respirations; increasing hoarseness;

coughing; singed nasal or facial hair; darkened oral membranes; smoky breath; productive cou

with black or gray sputum; decreased oxygen sat1

4. Res#iratory – Pneumonia – P+C

• :oals in "reatmentC clearer breath sounds normal breathing patterns no signs of hypoxia norm

chest x8ray no further complications

•

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atient is in meta)o!ic acidosis" Howe#er extensi#e Kussmau! respirations can !ead the patient to de#e!op respiratoryka!osis"

> Immune/Hematology - HI( C24 count – #at"ology< D0 ce!!s (&K& *-he!per ce!!s are a type of white )!oo

e!! that he!ps fight infection )y signa!ing D2 ki!!er ce!!s" D0 ce!!s are made in the sp!een, !ymph nodes, and thym

!and, which are part of the !ymph system" HI5 infection !eads to a progressi#e reduction in the num)er of D0 ce!!Medica! professiona!s refer to the D0 count to decide when to )egin treatment during HI5 infection" %orma! )!ood

a!ues for D0 ce!!s range from .//-67// ce!!s+mm9" D0 counts are used to assess the immune system of a patient"

atients often undergo treatments when the D0 counts reach a !e#e! of 9./ to .//cpm peop!e with !ess than 7// ceer micro!iter are at high risk of contracting &IDS defined i!!nesses" 

8> 3eurological - C( – Pat"ology< ere)ro#ascu!ar accident (5& resu!ts from sudden interruption of )!ood su

o the )rain" Stroke are either ischemic (caused )y partia! or comp!ete occ!usions of a cere)ra! )!ood #esse! #ia

hrom)osis or em)o!ism or hemorrhagic" Hemorrhage may occur outside the dura (extradura!, )eneath the dura matu)dura!, in the su)arachnoid space (su)arachnoid, or within the )rain su)stance itse!f (intracere)ra!"

1> SBR - initiate #rocess: Situation :ackground &ssessment ecommendation (S:& is a standardi;ed metho

ommunication used )etween hea!thcare staff and physicians to share patient information in a concise and structured

ormat" It impro#es efficiency and accuracy"

5#. 0- Mantou; test negatie - "he test is KnegativeL if there is no bump (or only a verymall bump) at the spot where the 2uid was in?ected1 > negative "% skin test usually means tou donQt have "%1 When documenting the nurse needs to note that there the size of the buthere is one location and that it was within 7, hours of the in?ection1,. D1 Gigh levels of ketones associated with high sugar levels in the blood and urine1 =ore water is drawn into the urineesulting in fre5uent urination1 !ombined with vomiting 8 from an upset stomach or possiblyue to a bout of 2u or illness 8 the body 5uickly loses too much water and electrolytes1ehydration can occur rapidly (within hours) and is very serious1 :ive '1J4 s many as 6' percent of all amputees experience pain inheir residual limb or as Kphantom painL which feels as if it is in the part of the limb that is missing1 *

esidual limb pain is believed to derive from in?uries to nerves at the site of the amputation1 >t the enf these in?ured nerve bers neuromas are formed1 "hese bundles of nerve bers may send out pain

mpulses in a random fashion or they may give oF pain signals when trapped by other tissue such asmuscle1 Boctors usually begin with medications and then may add noninvasive therapies such ascupuncture or transcutaneous electrical nerve stimulation ("9